Peak and trough levels

[weesyanne]

Hey everybody,

I recently had a run in with a fellow coworker who insisted that I should have ordered the Gentamycin peak and trough levels in advance for his patient. The dose was scheduled for early in his shift, at 0800, so I ordered the trough level for 0730, as that is the appropriate time for it to be drawn in our facility. I did not order the peak level due to not being exactly sure as to when he would get the dose up and running. I told him in report. He didn't order the peak, so he blamed me for making a mistake. I again informed him that the policy per the lab and pharmacy at our facility is that you cannot order the peak until the dose has been hung, as it may skew the values, and since I have no idea as to when exactly he would hang the dose, I cannot order it in advance. We have had a lot of difficulty in getting the P & T's ordered appropriately in the past, so that is how these departments have always instructed us to handle it. He still insisted that I was in error. I just dropped it with him and let my clinical supervisor know about the incident. Looking back at the orders, he was the one who had actually signed of the order for the P & T and he didn't order either of them.

I already know that I am correct, but asked for the clinical supervisors to review it with staff so that everyone was on the same page. My question is: Did I handle this appropriately or should I have further discussed this with the coworker myself? I just dropped the issue and went on with my business at the time of the confrontation. I am not in any position of authority and he insisted that I was wrong and actually seemed to get angry with me about it. :argue: I kept reiterating that it was not possible to get the timing correct by ordering in advance and that our hospital protocol has the person hanging the dose responsible for getting the order in correctly. This guy has a reputation for writing people for stuff and I don't want to be on his bad side. My other coworkers from both shifts involved back me up on this, but I am concerned about this nurse retaliating in some way. Any insight would be appreciated.

[wooh, BSN, RN]

I'd rather the offgoing shift not order peaks and troughs on meds I'll be hanging. Like you said, don't know when they'll actually be hung. It's so much easier to put an order in the computer than to change one already in there. Your coworker messed up and is looking for someone to blame.

[nursprl]

If you drew the trough, then it is understood that the med isn't to be administered until the level results have returned and reported to the physician. Administer the drug if level is sub- or within therapeutic range, hold if toxic. The nurse taking care of the patient is then responsible in drawing a peak level according to the recommedations of the drug book or the lab who runs the levels, if the drug is administered. Depending on how orders are placed, computerized or paper, many physicians will write an order that says something in the realm of "draw trough prior to next (third) dose and draw peak after next (third dose)."

You did your job by drawing the trough at 0730 in advanced of the 0800 dose; your coworker shouldn't complain or be upset at you for drawing a peak because a peak is drawn supposedly 30 minutes after infusion is completed and if you have already gone home, then it's out of your hands; it's in your coworkers hands. You were right bringing this up to your clinical supervisor and it may just need to be reinforced to all staff again when levels should be drawn. That way everyone is hopefully on the same page/level in term of drawing drug level. Just stand up for yourself, even if you don't like confrontation. I was the same way when I started nursing, but I had to overcome that and become assertive, especially when it deals with the safety health of our patients. Everyone in this field needs to be responsible for themselves and hold themselves accountable for their actions. If your coworker has nothing better to do than just write everyone up for every single small indiscretion, then I'd either talk to him about it and ask him to back off or talk to your supervisor. It sounds like he wants to place the blame on someone else for something he should have done.

Sorry for the rambling. I hope I got my point across. When in doubt, the drug manuals have when level should be drawn or call the lab and ask what is the hospital protocol. Hope this reply has some sort of insight to it.:)